Tom Murphy grew up revering his grandfather, a general practitioner in a small, rural town in Illinois. “His was the first face seen by babies when they came into the world and among the last ones patients saw when they died. He was a legend who had a profound influence on his community,” he says. Murphy, whose father and two uncles are also M.D.s, saw medicine as a culture that helps people. “On my application to medical school, I said that I wanted to carry on my grandfather’s legacy.”
Yet 10 years after working as a doctor, first as an internist and later (with additional training) as a rheumatologist, Murphy burned out. “I was depressed, physically exhausted, worn down. I became the type of physician that I never wanted to be — impatient, sarcastic, and occasionally dismissive of my patients,” he recalls. Even at home, he couldn’t leave work behind. “I might be at my daughter’s birthday, but my mind was someplace else.”
Murphy worked for a big hospital system that involved layers of bureaucracy, significant time constraints, and tons of paperwork. “I didn’t have the time to really enjoy my experience with patients,” he recalls. “Each day was a monumental struggle. I felt like Sisyphus. I’d get the boulder up the hill at the end of the day, and then I’d have to start all over again the next morning. I thought, I have to do this for the next 30 years.”
After some unsuccessful attempts to improve his situation, Murphy, at the age of 43, decided to retire. “I left the profession for about a year, but I started to miss it. I wondered how I could restructure my life so I would feel satisfied.” Murphy soon found a half-time position as a rheumatologist in Emmett, Idaho, a small, rural town. The job gives him time to write (he’s author of the book Physician Burnout: A Guide to Recognition and Recovery), lecture, and help other physicians who feel drained by their jobs. He adores his patients — mostly farmers and their families. “Now I practice the way I want to,” he says.
Burnout among physicians has reached epidemic proportions — and most doctors, unlike Murphy, haven’t found a remedy to what’s been called “an erosion of the soul.” The first national survey of the topic, taken in 2011, found that close to half of doctors — 45 percent — experienced at least one component of burnout, meaning they are emotionally exhausted, often treat patients as objects, or have lost their sense of purpose. Three years later, the survey numbers got worse. In 2014, burned-out doctors made up 54 percent of the profession. This type of exhaustion takes a huge toll on patients.
Research has shown that burned-out doctors are more prone to making medical errors. They are also more likely than other doctors to retire early or to otherwise leave the profession, which contributes to already existing physician shortages. “Burnout is a matter of national health importance,” declares Dr. Ramarao Yeleti, president of the Community Physician Network in Indianapolis.
Doctors have always worked long hours — a key factor in causing burnout in any profession — so why has the condition apparently become more pervasive? One answer: In recent decades, the practice of medicine has become much more exasperating. “In the ’60s and earlier, most doctors worked on a cash basis. The insurance market was small. There were not many regulations. Most doctors were in solo practices,” notes Dr. Paul DeChant, a former family physician who now advises healthcare managers for Simpler Consulting, an IBM company. Doctors could generally pick their hours and, accurate or not, the joke was you could never find one on Wednesdays because that was golf day. Today, most doctors are in large group practices. To keep the organization financially afloat, a primary care doctor may see 55 patients a day, usually for 15 minutes at a time. “Instead of being in charge of their days, many physicians have practice managers who tell them how long they have with patients, when they’re going to start, when their lunch break is, and so on. These physicians don’t have any autonomy, which is challenging for a lot of them,” says Dr. Colin P. West, co-director of a Mayo Clinic team that studies burnout.
In the last decade, what’s known as the “administrative burden” of doctors has increased alarmingly. According to one survey, doctors, on average, put through 37 prior authorization requests each week for medication or imaging from insurance companies, and the majority end up waiting a day or more for pre-approval. “This can suck the life out of physicians. You fill out a prior authorization to get a patient access to medication, then you’re on hold for 20 minutes, then you have to argue with someone who doesn’t know your patient’s situation, and 90 minutes later you’ve not made progress because it’s the end of the day for the person at the other end of the phone,” West says.
A primary care doctor may see 55 patients a day, usually for 15 minutes at a time.
A recent time-motion study found that for every hour of face time a doctor spends with patients, he or she puts in two hours doing clerical or data work, such as filling in electronic medical charts. After a day at the office, most physicians go home and then, after dinner, spend an additional hour or two at their computers. In several studies, doctors point to EHRs — electronic health records — as the biggest source of dissatisfaction in their practices. While intended to provide doctors (as well as insurers and the government) with useful information, the increasingly common use of EHRs in the last decade has had unintended consequences. “Tasks that took a few seconds in the pre-electronic health record world can take several minutes in the electronic world. Visit notes have become lengthy documents, formatted on a billing template, complicating rather than facilitating the work of finding key information,” complains Dr. Christine A. Sinsky, vice president of professional satisfaction for the American Medical Association.
The loss of these minutes affects patient care. “Doctors aren’t afforded the time to develop those significant game-changing moments where they really connect with their patients. Those are much rarer nowadays than they were in the past,” Murphy says. Connections also become harder because, during office visits, physicians routinely face away from patients as they type into the computer. “That’s crossed a tipping point for physicians in recent years. Physicians are crying out for a return to working while facing patients,” says West.
Socializing with colleagues — one of the pleasures of any job — has also become more difficult. Doctors’ lounges in hospitals are empty or non-existent. “The administrative burden leaves no time for water-cooler talk. You’re racing, you’re on roller skates, all day,” says Dr. Suzanne Koven, writer-in-residence and a primary care physician at Massachusetts General Hospital and the daughter of a Brooklyn physician. “Doctors, for good reasons, are much more protective of boundaries in their private lives than they used to be. In my father’s day, the wife didn’t work. The doctor could stay at work as long as necessary. The social life revolved around other doctors. Now everyone is in a rush to get home to their families.”
Colin West, an internist, has been studying physician burnout since 2003 and, along with two other doctors, directs the Mayo Clinic’s Physician Well-Being Program, an unusually productive research outfit. Working out of their Rochester, Minnesota, offices, West and his colleagues have authored well over 100 articles on the topic. “In the beginning, we had little preconceived notion as to how prevalent burnout is or what its implications for patients might be. But every time we asked a question, we got concerning answers,” West recalls. “This work,” he concedes, “risks feeling like doom and gloom.” However, just in the last 18 months, West has become optimistic that physician burnout in the U.S. will be reduced. “There’s been a remarkable uptick in recognition and attention to these issues by major medical organizations, such as the American Medical Association, the Association of American Medical Colleges, and the Accreditation Council for Graduate Medical Education. It’s very difficult to make system-level changes unless major organizations and what I like to call ‘enlightened leaders’ call for important policy changes.”
In recent years, the Mayo research group has turned its attention to looking at solutions to burnout. A study published last year found grounds for optimism. It determined that various attempts to reduce burnout have resulted, on average, in a 10 percentage-point drop (from 54 percent to 44 percent) in the number of doctors who succumbed to the condition. “That shows we can at least dent the curve,” West says. Concludes the AMA’s Sinsky, “A lot of very little elements can add up to very big changes.”
For every hour of face time a doctor spends with patients, he or she puts in two hours doing clerical or data work.
Solutions to burnout come in two main forms: those that center on changing physicians and those that try to modify organizations. It is not expensive for a medical organization to initiate programs that help doctors reduce job stress, and this is where many healthcare organizations start. Mindfulness-based stress reduction, which helps people focus on what’s happening around them, has been around since the late ’70s. It’s often taught in classes offered to community members at medical schools and has been validated as a stress reducer in myriad studies, including at least one that shows it lowers burnout in nurses. Other possibilities include resilience training, which aims to help doctors bounce back from setbacks. At Stanford Health Care in California, physicians are offered the option of taking a course in self-compassion. “Physicians are really obsessive-compulsive perfectionists, and they beat themselves up when there’s an error,” says Dr. Bryan Bohman, an anesthesiologist and associate chief medical officer for the Stanford system. “The course teaches them that when something goes wrong, it’s a reason to improve rather than to blame themselves.” Many experts, however, say it’s necessary to go beyond giving courses to doctors. “Mindfulness and similar training are easier to implement than changing the workflow. But changing the workflow is more important — it changes the causes of burnout,” says DeChant, who reports on 26 successful practices in his book Preventing Physician Burnout.
At the top of the wish list is improving the electronic health record experience and other data entry work. “We found that nobody had gone back to physicians after their initial training on EHR to teach them new tricks,” says Dr. Patrick McGill, a family medicine doctor who’s spearheading research on patient care redesign at the Community Health Network, a network of 600 primary care doctors in the Indianapolis area. “So we gave physicians additional one-on-one instruction to improve their efficiency,” he adds. If needed, doctors were also taught how to use a speech recognition program so they can dictate their notes into a computer. In some instances, physicians were given scribes — nurses or medical assistants who take notes as they talk with patients — to do the data entry. One of Community Health’s themes is reducing clicks. In pilot programs, doctors are now able to log on to the computer by swiping their ID cards rather than by having to type in their passwords. It’s also possible to create shortcuts by, say, combining frequently recurring orders for blood tests into a one-click operation.
A seemingly unrelated change — moving physicians and their team members (nurses, medical assistants, nurse practitioners, and so on) near each other — can reduce use of messages, which typically go through the EHR system. When doctors and staffers simply talk to each other rather than write notes, both save time during the day. Before making innovations, Community Health determined that its doctors were spending two to three hours of work at night on the EHR, totaling 25 to 30 hours a month. “In some pilot programs, that number went down to less than two hours a month,” McGill says. “The offices were transformed — and staff satisfaction went up.”
Plenty of other innovations are possible, many mapped out by the AMA at stepsforward.org. Among primary care practices, one strategy is to have patients take laboratory tests a few days before their office visits, so results are available when the doctor and patient meet, giving them a chance to discuss possible actions in person. By sparing the doctor from having to make phone calls about the tests, one medical center cited in research led by Sinsky has cut post-appointment results reporting by at least an hour a day.
Similarly, streamlining prescription renewals can save time for physicians. For patients whose chronic conditions are well-controlled, doctors can write prescriptions that last a year so that patients don’t need to call for renewals every few months. Well-developed protocols can allow nurses to write many prescriptions and handle pre-authorization requests. Behavioral health specialists can handle issues such as depression and anxiety, which are common complaints in primary care practices. “That’s probably one of the biggest things we’ve done,” Community Health’s McGill says. “A physician is no longer stuck in the room with a person whose problem he’s not really trained to deal with.”
Some innovations seek to enhance physicians’ sense of meaning by building a feeling of community. The Mayo Clinic springs for a restaurant lunch every two weeks for groups of five or six physicians who are tasked with talking about their professional experiences for at least the first 15 minutes of the meal. At Harvard, Dr. Koven leads once-a-month, two-hour sessions in which 20 to 25 physicians and staff meet in a small room with a noisy ventilation system and fluorescent lights to discuss a short piece of literature germane to medicine. “When people come to this group, they’re hungry to talk about their day and their job. They’re dealing with other people’s traumas. It’s a lot of stories not to tell anyone,” Koven says. And at Stanford, emergency medicine doctors can bank “credits” for helping out other physicians by, say, mentoring them or taking on an unscheduled shift. “Credits are selected to decrease home- or job-related stress, such as cleaning of the house, Blue Apron food delivery, time with an executive coach, or grant-writing assistance,” says Dr. Rebecca Smith-Coggins, an emergency medicine physician at Stanford Health Care. The biggest gift in the program, she says, is the feeling of being appreciated.
Many experts feel that the key to conquering burnout is helping physicians regain a sense of meaning in their work. “Medical students begin their training with better mental health, better well-being, and lower burnout rates than their age-matched college graduates who are not medical students,” West says. “They are idealistic, but within a year or two, they’ve run up against a system that works to grind them down. Doctors have to get back to the naive idealism of the beginning medical students, because they have it right.” How can the medical system get there? “A little bit of fun, some tech changes, and a lot of support,” answers Dr. Adrienne Boissey, chief experience officer of the Cleveland Clinic Health System.
Nancy Stedman is an award-winning journalist who has written for a variety of publications, including The New York Times, Health magazine, and Prevention.
Coping with a Stressed-Out Doctor
How to get the most out of a physician who is distracted, uninterested, impatient, or otherwise harried.
Talk to the face: “Wait for the physician to finish typing into the computer. In other words, wait until you have the doctor’s full attention before asking an important question,” says Dr. Christine A. Sinsky, vice president of professional satisfaction for the AMA. Almost no one is truly able to multitask.
Write stuff down: “Bring in an accurate list of medications — including dosages and how often you take the pills. Write down your symptoms before you go in,” Sinsky suggests. Also, bring medical records, such as test results, diagnoses, treatment plans, and medications. “The more prepared you are, the less time is needed for data collection and the more time the doctor has for deep thinking.”
Be kind: “Even if your doctor fast-forwards into the session, pause to check in with him or her as a human being,” recommends Dr. Adrienne Boissey, chief experience officer of the Cleveland Clinic Health System. “Say, ‘Hey, how are you?’ Patients underestimate the value of gratitude and thanks.”
Make a connection: “If you’re uncomfortable with the care you’re receiving or think the doctor is not engaging with you, you could step back, just as you would with one of your friends, and say something like, ‘You know what, you seem like you’re off today, is anything wrong?’” says Dr. Bryan Bohman, associate chief medical officer at Stanford Health Care. Dr. Thomas Murphy, a rheumatologist in Idaho, adds a caveat: If you’re going to question a doctor this way, it must be done with “complete kindness.” Otherwise, the physician may worry you’re about to file a complaint.
If all else fails, find a new doctor: “You’re probably not going to change a provider. You need to take care of yourself,” Murphy says.
This article is featured in the July/August 2017 issue of The Saturday Evening Post. Subscribe to the magazine for more art, inspiring stories, fiction, humor, and features from our archives.